| NPI | 1316385974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: OR MD213783) |
| Additional Taxonomies | 2085R0001X (Licence: WA MD61484558) |
| 2085R0001X (Licence: NY 294479) | |
| Enumeration Date | 2013-06-05 |
| Last Update Date | 2025-12-08 |